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Science

Understanding depression in Asia

As humans, we tend to chase after the global notion of "success" while neglecting its true value, which isn't fame, fortune or power but "emotional well-being."

     According to the World Health Organization's first report on suicide prevention, released Sept. 4, 803,900 people died by suicide worldwide in 2012. Of them, 39.1% were in low- and middle-income countries in the WHO South-East Asia region, which includes India, Indonesia, Thailand and North Korea; 16.3% were in the WHO Western Pacific Region, which encompasses China, Vietnam and Mongolia. Including Japan, where some 30,000 people committed suicide that year, Asia made up about 60% of global cases.

     Experts say this large share is due to suicide being relatively under-researched in Asian countries, with limited preventive measures in place compared with the West.

     However, a recently published study featuring 547 participants with major depressive disorder from China, South Korea, Taiwan, Singapore, Malaysia and Thailand, sheds light on MDD and its link to suicide.

     The study was conducted from 2008 to 2011 by a team from 13 institutions and members of the Mood Disorders Research: Asian and Australian Network. It included a survey focusing on how so-called melancholic features, hostility, and socio-demographic factors are associated with suicide risk in MDD patients.

Melancholia and hostility

"The most prevalent psychiatric diagnosis among suicide committers is MDD," said researcher Hong Jin-pyo from South Korea's Ulsan University College of Medicine, who was involved in the study. "MDD patients are prone to feel guilt and have nihilistic ideas with or without psychological stress."

     The research showed that the risk of suicide was higher in Korean and Chinese MDD patients with melancholic features than Thais, Indians and Malays. Out of the 547 patients, 32.4% suffered from melancholic depression. A previous study by an Australian university also showed that melancholic depression represents 20% to 30% of the clinically depressed population.

     Melancholic features include excessive guilt, loss of pleasure, lack of appetite, early morning awakening and retardation, to name a few. They are generally associated with greater depression severity and younger age. The 18-29 age group represented 29.4% of the MDD patients with melancholic features, the highest among all age groups. The 30-39 range was second at 27.1%.

     Divorced or separated individuals made up 57.4% of MDD patients with melancholic features. "Divorced individuals may be at risk of suicide because they became lonely," Hong said. "But we could say that the individual was suicidal and mentally ill, leading his/her partner to leave."

     Past studies have revealed that MDD with melancholic features made up 29% of all suicidal cases, four times higher than MDD alone. "Suicide can be prevented by increased mental health literacy," said researcher Albert Yeung from the Massachusetts General Hospital Depression Clinical and Research Program.

     He added that patient education, mental health literacy and increased awareness of support systems can reduce the risk of suicide, along with mental health professionals recognizing early signs of suicidal behavior and responding quickly.

     Research has also shown that hostility is associated with moderate to high suicide risk in MDD patients and increased risk of violent suicide attempts, like the use of firearms. However, the results were different with MDD patients displaying both hostility and melancholia. MDD with high hostility and melancholia made up 24.5%, while MDD with low hostility and melancholia accounted for 75.8%. This reflects that high hostility hides the effects of melancholia on suicide risk in MDD patients.

Associated factors

The study exposed that approximately 26% of the female participants suffered from high suicidality, with the male-female ratio of the subjects being 195 to 352. Previous research also found that in Asia, women were more inclined to commit suicide than men, even though more men die by suicide globally. The exact reasons for this are unknown, according to Yeung.

     "There is some consensus among researchers that suicide involves a strong component of impulsivity, and the methods of suicide are frequently influenced by what means are immediately available," Yeung said. "In rural China, many women chose to use insecticides because they were widely available."

     Besides gender, the study also examined other socio-demographic characteristics, such as age, religion, marital status and education level, among others. In Malaysia and Thailand, around 10% of MDD patients were classed as having high suicidality, whereas in South Korea, it was over 40%. Differences in the suicide rates in Asian countries are related to various factors like climate, financial status, work environment and social pressure.

     A case in point: South Korea and China experience more drastic weather changes than Thailand or Malaysia, and such changes may add to the high suicide rate, according to one study.

     The Mood Disorders Research study revealed that Hindu and Muslim patients were less likely to commit suicide, which was the same as prior reports that following a religion that prohibits suicide leads to low suicide rates. Among the 20 Hindu patients, only one was suicidal, while 36% of atheist patients were classed with high suicidality.

     Education level played a role as well -- 80% of patients with secondary qualifications were highly suicidal, while the figure for those with higher education was 32%.

     The study did have limitations. "In a cross-sectional study, there is no temporal distinction" between exposure to a risk factor and the response, or suicidality variables, said co-researcher Dianne Bautista from National University of Singapore. "In general, one cannot generalize causality based on a cross-sectional study design."

     "Future studies are expected to identify risk factors for suicidality," Hong said. "We have published six papers previously and are still doing this kind of work."

Collaborative efforts

Yeung sees some promising progress. "There have been concerted efforts between governments and mental health professionals in many Asian countries to try to educate and increase awareness of mental disorders, particularly depression, over the past decades, with encouraging results," he said. The Mood Disorders Research study itself is a collaboration of psychiatrists who do both clinical practice and research.

     Besides professional endeavors, families are crucial for preventing suicide, too. "Simply put, the very thought of suicide makes death seem so much more comforting," said a 25-year-old Indian man suffering from depression. "Loved ones should show their continuous love, support and commitment toward depressed family members."

Yasmin Pascual Khalil is a chemical engineering graduate from Curtin University and freelance journalist.

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